Advantage PPO Saver

Not all health plans work the same way. This website will explain how the Advantage PPO Saver plan works, so be sure to read through it carefully to understand your plan.

You can also visit mytuftshealthplan.com, our secure members-only site, to learn the details of the specific plan your employer has chosen for you. And be sure to read your Benefit Document, available at mytuftshealthplan.com, to see a complete list of your specific plan’s covered and non-covered benefits.

Knowledge is power, and knowing how your plan works will give you the power to plan for and control your out-of-pocket costs.

The goal is more affordable healthcare.

Our goal at Tufts Health Plan is to enable every employer to offer affordable healthcare to their valuable employees. So we try to provide as many options as possible.

The Advantage PPO Saver plan is one such option, and it in turn offers options of its own. It is a high deductible health plan (HDHP) as defined by the Internal Revenue Service, and may be paired with a Health Savings Account (HSA) available through other institutions, including local banks. HSAs are accounts that can be used to pay medical expenses, while offering certain tax advantages. The IRS lists the benefits of an HSA as follows:

You can claim a tax deduction for contributions you, or someone other than your employer, make to your HSA even if you do not itemize your deductions on Form 1040.

Contributions to your HSA made by your employer (including contributions made through a cafeteria plan) may be excluded from your gross income.

The contributions remain in your account until you use them.

The interest or other earnings on the assets in the account are tax-free.

Distributions may be tax-free if they are used to pay for qualified medical expenses.

An HSA is “portable.” It stays with you if you change employers or leave the work force.

Here’s how it works.

You enroll in an Advantage PPO Saver plan, then set up a Health Savings Account (HSA) at any financial institution that provides HSA services. You decide how much you’d like to contribute (up to maximum IRS limits), either one-time or on an ongoing basis. The account rolls over automatically every year, and you are eligible to contribute to the account as long as you are enrolled in an HDHP-compliant medical plan. And you can keep this account even if you change jobs.

You can learn more specific details about the Advantage PPO Saver medical plan by reading your Benefit Document. It’s hard to know what the future holds, but with the Advantage PPO Saver plan and an HSA, at least you’ll be a bit more prepared.

This information has been provided for informational purposes only. While we aim to ensure that content is current, accurate and complete, Tufts Health Plan makes no representations or warranties regarding its accuracy or completeness, and the information provided should not be construed as legal or tax advice or as a recommendation of any kind. Please consult your own tax advisor or legal counsel with respect to your individual circumstances and needs.

Cost sharing.

The Advantage PPO Saver plan incorporates a fee structure that does require some cost-sharing on your part. This cost-sharing is primarily in the form of two components: the deductible and the copay.

The Deductible

The deductible is the amount you must pay before your insurance kicks in. Not everything you go to the doctor for is subject to the deductible; check “Services Subject to Deductible” below for details.

To confirm the deductible amount that applies to your plan, check your benefit documents (Summary of Benefits and Coverage, or Evidence of Coverage). If you are enrolled in family coverage, your plan will have an individual deductible and a family deductible. The individual deductible will work in one of two ways:

Each family member has to meet the individual deductible before insurance kicks in. This is known as a “capped” deductible.

Each family member has to meet the full family deductible before insurance kicks in. This is known as an “aggregate” deductible.

Here’s an example of how the deductible works when it is capped:
Let’s say your plan has a $1,000 family deductible and a $500 individual deductible. You’re working in the yard, you have an accident, and you have to make a trip to the emergency room. Your maximum responsibility as an individual would be $500, not the entire $1000. Now let’s say you have another accident in the same plan year. Your individual deductible of $500 has already been met, so you’re not responsible for any deductible amount.

Now let’s say your spouse needs surgery. Your family is now responsible for the remaining $500 deductible, since it’s a different individual. But now your total amount paid toward your $1000 deductible has been met. The next time anyone in your family needs medical services that are subject to the deductible, you don’t have to worry about the deductible. The deductible for the plan year has been met.

Here’s an example of how an aggregate deductible works:
Let’s say your plan has a $1000 family deductible and a $500 individual deductible. You’re working in the yard, you have an accident, and you have to make a trip to the emergency room. Your maximum responsibility as an individual would be the entire $1,000 of the family deductible. Now let’s say you or another family member has another accident in the same plan year. Because your family deductible of $1,000 has already been met, you will not be responsible for any additional deductible amount.

The Copay

Regardless of the status of your deductible, there are some services that may also require a copay. A copay is a fee that you pay as partial payment for certain services. For instance, a visit to the doctor’s office often requires a copay. That means you pay, for example, $20 out-of-pocket as your copay. Whether or not your deductible has been met, if a copay is required for the type of medical service you want, you are responsible for the copay.

A Word About Coinsurance

There’s one more component of the Advantage PPO Saver plan’s fee structure that bears mentioning. It’s called coinsurance, and it applies primarily to durable medical equipment (such as a wheelchair or crutches), hearing aids, low-protein foods and prosthetics. If you require any of those items, you would share a percentage of the cost.

In some cases, coinsurance may also apply to other items. You can find the specifics of your plan, including the exact amount of your coinsurance, by reading your Benefit Document or by visiting mytuftshealthplan.com.

The Out-of-Pocket Maximum

You’ll be glad to know there’s a limit on what you may possibly pay during a calendar year. It’s called an Out-of-Pocket maximum. The Out-of-Pocket maximum is the most you can pay during your coverage period (typically one year) for your share of the cost of covered services.